When is Robotic Minimally Invasive Surgery the Approach of Choice?

A 42 year-old woman presents in the outpatient obstetrics and gynecology clinic with severe, uncontrolled pelvic pain, painful bowel movements, and constipation. The patient has a history of stage IV endometriosis and had conceived via in-vitro fertilization (IVF). The patient now desires definitive therapy; she has completed childbearing and she had unsuccessful medical management of her symptoms with oral contraceptives and a progestin IUD. Recent ultrasound revealed a large endometrioma in the right ovary. Colonoscopy results indicated deep endometriosis of the sigmoid colon.

Stephanie Estes, M.D., of Penn State Hershey Obstetrics and Gynecology says, “In complex cases like this, a minimally invasive surgical procedure using robotic technology in a single operation offers the best odds for success, both procedurally and with a good recovery. A gynecologic surgeon would begin with a hysterectomy, and then a colorectal surgeon would resect the affected portion of sigmoid colon en bloc, to complete the procedure.” Estes continues, “With the robotic surgical tools we use, there is definitely better dexterity and enhanced 3D visualization of tissue and organs, compared to an open abdominal approach. This minimally invasive approach is really key for complex cases with widespread pathology, to avoid injury to delicate surrounding tissues.”

Welcome to the OB/GYN Report

John T. Repke, M.D., F.A.C.O.G.

Greetings from Penn State Hershey! I am pleased to share with you the first issue of the OB/GYN Medical Report from the Department of Obstetrics and Gynecology of the Penn State College of Medicine and Penn State Milton S. Hershey Medical Center.

We recognize the importance of collaboration among our peer physicians, and regularly work with other academic medical schools to propel our field forward through new research discoveries, better patient care, and educating new physicians. Our hope is that this publication helps inform physicians like yourself of some of this important work, and that you find it to be a valuable resource.

In the coming year, this publication will feature Penn State Hershey clinicians and researchers who are helping to raise current standards of patient care and shape the future of OB/GYN practice. Our department features five divisions – General OB/GYN, Maternal-Fetal Medicine (MFM), Reproductive Endocrinology and Infertility (REI), Gynecologic Oncology, and Urogynecology/ Minimally Invasive Gynecologic Surgery.

Resident Training Program Emphasizes Minimally Invasive Hysterectomies: Achieving a New Standard of Patient Care

A residency training program that stresses minimally invasive hysterectomies is proving to be not only feasible, but a highly effective strategy for providing valuable surgeon training and improving patient outcomes. As leaders of Penn State Milton S. Hershey Medical Center’s Division of Urogynecology and Minimally Invasive Gynecologic Surgery, Gerald Harkins, M.D., and his colleague Matthew Davies, M.D., have closely tracked resident performance and patient outcomes. At the September 2013 Minimally Invasive Surgery Week and Endo Expo in Reston, VA, Harkins and his colleagues presented the first full twelve months of outcomes data from the training program. Among 537 patients who underwent hysterectomies for benign indications including abnormal bleeding, pelvic pain, fibroids, endometriosis, and prolapse/incontinence in a single year, 96 percent underwent minimally invasive surgery, either with vaginal or laparoscopic approach with a resident as the lead surgeon or the first assist, explained Harkins in an interview. Training new physicians and surgeons to provide up-to-date standards of care, including the use of minimally invasive techniques and robotic surgery, is a major challenge facing the health care field today. “Most physicians with established practices don’t have the necessary training in minimally invasive techniques, and so despite evidence that such techniques are safer and more cost-effective,¹ 60 percent of hysterectomies are still open procedures,” says Harkins. Recent nationwide OB/GYN residency training data suggest most U.S. trainees continue to lack needed minimally invasive surgical experience, with the average surgical resident completing sixty-four abdominal, eighteen vaginal, and twenty-three laparoscopic hysterectomies during training.²

Kristin Riley, M.D., fellow, assists Gerald Harkins, M.D. during minimally invasive gynecologic surgery. As part of its residency training program, residents act as lead surgeon or as first assist in 96 percent of the minimally invasive hysterectomy procedures at Penn State Milton S. Hershey Medical Center.